Wholesale Account Application

Synaptent LLC / dba LiftMode

425 Barclay Blvd., Lincolnshire, Chicago, IL 60069 / Tel (888) 228-9993
E-mail liftmode@liftmode.com / FAX (312) 577-1689

For OFFLINE / PHONE wholesale ordering, please complete, sign and submit this application form in full.

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Date of Signature:

Business EIN #:

Legal Business Name:

Legal Owner(s):

DBA (if applicable):

In business since:

Vendors License/Resale #:

Description of your business:

Shipping Address:

City:

State/Prov:

Postal/Zip Code:

Country

Manager:

Others authorized to place orders:

Phone:

Fax:

E-mail:

Web Site

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